657
ARTICLE
Evaluation of impact of posterior phakic
IOL implantation on biometry and
effectiveness of concomitant use of anterior
segment OCT on IOL power calculation for
cataract surgery
Masayuki Ouchi, MD, PhD
Purpose: To evaluate the effects of phakic intraocular lens (pIOL)
implantation on the intraocular lens (IOL) power calculation and subse-
quently to evaluate the effectiveness of concomitant use of anterior segment
optical coherence tomography (AS-OCT) against biometric changes.
Setting: Masayuki Ouchi Eye Clinic, Kyoto, Japan.
Design: Prospective consecutive case series.
Methods: 100 patients (100 eyes) who underwent pIOL implan-
tation were enrolled. In each eye, biometry was performed using
partial coherence interferometry (PCI) and AS-OCT. Pre-pIOL and
post-pIOL implantation IOL power calculation using SRK/T (S),
Haigis (H), and Barret Universal II (B) formulas was compared.
Results: 100 patients (100 eyes) were included. Anterior chamber
depth (ACD) was significantly shorter at post-pIOL implantation for
both PCI (P < .001) and AS-OCT (P = .05). When using PCI, the
I
n addition to laser in situ keratomileusis, another type
of corrective surgery for severe myopia involves the
implantation of a posterior phakic intraocular lens
(pIOL). With the advent of models with perfusion ports
in the center of the IOL that improve aqueous humor
flow, this procedure has become increasingly common
in these years.1 Furthermore, recently, the number of
individuals with a history of refractive surgery who re-
quire cataract surgery has increased. Alterations in
corneal morphology caused by laser in situ keratomi-
leusis surgery change the calculations used to determine
corneal curvature and postoperative effective lens po-
sition, thereby markedly affecting the calculations of
intraocular lens (IOL) power.
Furthermore, the number of patients who have un-
dergone pIOL refractive surgery and subsequently require
Submitted: May 23, 2021 | Final revision submitted: August 4, 2021 | Accepted: August 25, 2021
Masayuki Ouchi Eye Clinic, Minami-ku, Kyoto, Japan.
Corresponding author: Masayuki Ouchi, MD, PhD, Masayuki Ouchi Eye Clinic, 9-1 Nishikujo Ohkuni-cho, Minami-ku, Kyoto 601-8449, Japan.
Email: mouchi@skyblue.ocn.ne.jp.
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS
Published by Wolters Kluwer Health, Inc.
crystalline lens surface was misidentified in 75% of eyes, and in these
eyes, the ACD difference between pre-pIOL and post-pIOL im-
plantation exceeded that with both PCI and AS-OCT. The estimated
IOL power was significantly lower at post-pIOL implantation ac-
cording to the H and B formulas (both P < .001) but remained
unchanged by the S formula. However, no difference was observed
when AS-OCT–derived ACD and lens thickness (LT) values were
introduced in the H (P = .16) and B (P = .55) formulas.
Conclusions: Misidentification of the lens surface occurs in many
pIOL-implanted eyes with PCI measurements and could influence
the power calculation with H and B formulas while leaving the S
formula unaffected. AS-OCT–derived ACD and LT value sub-
stitution is recommended for H and B formulas.
J Cataract Refract Surg 2022; 48:657–662 Copyright © 2021 The Author(s).
Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS
cataract surgery is expected to increase in the near fu-
ture.2,3 Although pIOL implantation surgery does not
alter corneal morphology, it can potentially change the
anterior chamber depth (ACD), and the presence of the
pIOL itself may further affect the measurements of light
and other properties of the anterior chamber.4,5
A previous report describing IOL power calculation after
pIOL implantation considered only changes based on
previous generation partial coherence interferometry
(PCI), and the impact of change in ACD on IOL power
calculation was unclear, which also needed to be ad-
dressed.6 Thus, in this study, we examined the effects of
pIOL implantation on the calculation of IOL power for
cataract surgery using PCI and subsequently evaluated the
effectiveness of concomitant use of anterior segment optical
coherence tomography (AS-OCT).
0886-3350/$ - see frontmatter
https://doi.org/10.1097/j.jcrs.0000000000000811
658 IMPACT OF PIOL IMPLANTATION ON BIOMETRY AND IOL CALCULATION
METHODS
Subjects
This study was performed in accordance with tenets of the
Declaration of Helsinki. After being approved by the Masayuki
Ouchi Eye Clinic Ethics Committee, it was registered in the UMIN
clinical trial registry system (UMIN000038359). Informed consent
was obtained from all included cases.
The subjects were 100 right eyes from 100 individuals who un-
derwent pIOL (EVO + Visian ICL, Staar Surgical Corp.) implantation
for myopia or myopic astigmatism and who completed all the
scheduled follow-up visits at the Masayuki Ouchi Eye Clinic between
January 2020 and April 2021, with all procedures performed by the
same surgeon. Cases in which the ACD was < 2.8 mm or in which
ophthalmological illnesses other than refractive abnormalities were
present were excluded. Subjects consisted of 36 men and 64 women,
with a mean age of 31.1 ± 8.6 years (21 to 57 years). These subjects
were included in a prospective trial.
Measurements
The following parameters were compared before and 1 month
after insertion of the pIOL: estimated power of the inserted IOLs
(aimed at emmetropia); the ACD and lens thickness (LT),
measured using PCI (IOL Master 700, Zeiss Corp.) and AS-OCT
(CASIA2, TOMEY Corp.). The misidentification rate, that is, the
percentage of cases in which the anterior surface of the pIOL was
misidentified during PCI as the anterior surface of the IOL, was
also noted, and the ACD and LT was measured in such cases.
ACD measurements using PCI have been reported to increase
significantly when the pupil is dilated; thus, all measurements were
performed with the pupil undilated.7 When PCI measurements
taken after pIOL implantation were captured such that the seg-
mentation line on the postoperative anterior segment image (which
indicates the anterior surface of the crystalline lens) was properly
drawn on the anterior surface of the IOL, the measurement was
labeled “no misidentification present” (Figure 1, A). However, when
the segmentation line was drawn on the anterior surface of the pIOL
(or anywhere other than on the anterior surface of the IOL), the
measurement was considered as “misidentified” (Figure 1, B).
Furthermore, postoperative ACD and LT measurements using
AS-OCT were manually corrected for misidentification of the
anterior surface of the crystalline lens using the semiautomatic
trace function preloaded onto the machine so that all the ACD
values measured using AS-OCT coincide with the distance be-
tween corneal epithelium and crystalline lens surface. Visual
acuity, subjective and objective refraction, axial length, and cor-
neal radius of curvature were measured as well.
Visual acuity was measured using a space-saving chart (SSC-
370, Nidec Corp.). Objective refraction was measured using an
autorefractometer (ARK1, Nidec Corp.). After obtaining objective
refractions using the autorefractometer, the results were refer-
enced as a starting point for a full manifest refraction. PCI was
used to measure axial length and corneal radius of curvature.
To calculate IOL power, the target IOL was set as the SN60WF
model (Alcon Corp.) and three formulas were used to calculate the
Volume 48 Issue 6 June 2022
IOL power necessary to set estimated postoperative refraction to
emmetropia, using the same machine. The formulas were the
SRK/T formula (S formula), the Haigis formula (H formula), and
the Barret Universal II TK formula (B formula). PCI measure-
ments were performed at least 6 times automatically, and the
measurement values were produced after reproducibility was
confirmed. The constants used in the various calculation formulas
were taken from values published by the User Group for Laser
Interference Biometry. These values were as follows: 119.1 (S
formula); a0: 1.268, a1: 0.342, a2: 0.233 (H formula); and LF:
1.94, DF 5.0 (B formula).
Size of the pIOL was determined using the K-S and N-K
formulas given in the pIOL sizing mode of the AS-OCT machine.
Data from subjective visual acuity tests were used as input data for
determining spherical/cylindrical power and the targeted insertion
axis for the toric model.
Statistical Analysis
All measurements are expressed as mean ± standard deviation.
The R statistical software package (R Development Core Team)
was used for all statistical analyses (https://www.r-project.org/).
After creating Bland-Altman plots, preoperative and post-
operative ACD and LT measurements were tested for fixed error
using the one-sample t test. Repeated measures analysis of vari-
ance was used to compare the preoperative and postoperative IOL
powers obtained using each of the calculation formulas, following
verification of normal data distribution with the Shapiro-Wilk
test. The threshold of statistical significance was set at 5%.
RESULTS
Refraction, Visual Acuity, and Complications
As an intraoperative complication, in 1 eye, the haptic of
the pIOL was broken during insertion; the IOL was ex-
tracted, and the operation was performed once again at a
later date. Adjustment of the toric axis (with 15 degrees)
after surgery was required for 1 eye. The intraocular
pressure did not exceed 21 mm Hg in any of the cases at
1 month postoperatively.
Table 1 shows preoperative and postoperative visual acuity
and refraction data. In all cases, postoperative visual acuity
was improved, and postoperative spherical/cylindrical power
was smaller than the preoperative values both subjectively
and objectively. There was no difference in corrected visual
acuity.
Biometry
In 75 of 100 eyes (75%), postoperative PCI measurements
misidentified the anterior surface of the pIOL as the an-
terior surface of the crystalline lens, placing the segmen-
tation line there.
Figure 1. Identification of the anterior
surface of the crystalline lens using partial
coherence interferometry following pos-
terior pIOL implantation. (A) No mis-
identification: The third segmentation line
from the left (arrow) correctly identifies
the anterior surface of the lens. (B) Mis-
identification: The segmentation line has
misidentified the anterior surface of the
pIOL as the anterior surface of the
crystalline lens. pIOL = phakic IOL
 IMPACT OF PIOL IMPLANTATION ON BIOMETRY AND IOL CALCULATION 659

Table 1. Preoperative and Postoperative Acuity and Refraction.

pIOL UDVA CDVA Subjective Subjective Subjective Objective Objective Objective IOP
implantation (logMAR) (logMAR) spherical (D) cylindrical (D) SE (D) spherical (D) cylindrical (D) SE (D) (mm Hg)

Pre 1.36 ± 0.35 0.10 ± 0.11 6.98 ± 2.96 0.88 ± 1.03 7.41 ± 3.06 6.85 ± 3.27 1.16 ± 1.15 7.65 ± 3.14 14.5 ± 2.6
Post 0.11 ± 0.16 0.11 ± 0.05 0.04 ± 0.19 0.15 ± 0.30 0.11 ± 0.23 0.10 ± 0.44 0.58 ± 0.35 0.36 ± 0.42 13.6 ± 2.6

Post = postoperative; Pre = preoperative; SE = spherical equivalent refraction

Figure 2 depicts Bland-Altman plots for preoperative and
postoperative ACD and LT measurements collected using
PCI and AS-OCT. ACD measurements collected using PCI
exhibited a positively skewed distribution (Figure 2, A), and
a fixed error was observed (P < .001). LT values were
skewed negatively (Figure 2, C), and a fixed error was also
observed (P < .001). However, in comparison, AS-OCT
measurements exhibited only a small amount of variance in
both ACD and LT (Figure 2, B and D).
Table 2 lists preoperative and postoperative biometry
values. Axial length and the mean of the steepest/flattest
meridian power remained unchanged between preoperative
and postoperative measurements. However, significant dif-
ferences were seen between ACD and LT values measured
preoperatively and postoperatively by means of PCI (both P <
.001). When categorized by the presence or absence of
misidentification, a preoperative to postoperative difference of
0.07 mm was observed for cases with no misidentification;
however, in cases where misidentification occurred, the mean
preoperative to postoperative difference was 0.5 mm or more
in ACD. Thus, a large difference was observed. By contrast, LT
was measured as longer in cases with misidentification than in
those without misidentification. Finally, in AS-OCT mea-
surements, measured ACD was significantly shorter post-
operatively (P = .05), but this difference was smaller than that
seen with PCI. Moreover, no difference was observed in LT.
Calculation of IOL Power
Table 3 lists preoperative and postoperative results for
IOL power calculations. No difference was observed in
preoperative and postoperative values calculated using the
S formula (P = .29), but when using the H formula and B
formula, postoperative values were significantly smaller than
preoperative values (both P < .001), although no difference
was seen in comparison with non-misidentified cases be-
tween preoperatively and postoperatively, both in the
H formula (10.40 ± 3.43 and 10.38 ± 3.25; P = .80) and in the
B formula (10.20 ± 3.20 and 10.13 ± 3.05; P = .53). However,
after recalculating postoperative values by substituting
AS-OCT–measured ACD and LT values in misidentified
cases, no significant difference with preoperative values was
observed (P = .16, P = .55, respectively).
DISCUSSION
Using three main IOL power calculation formulas, we
demonstrated the effects of previous pIOL surgery on the
calculation of IOL power for cataract surgery. Although
values calculated using the S formula did not change from
preoperatively to postoperatively, significantly lower IOL
power was calculated postoperatively when the H and B
formulas were used after pIOL implantation. However,
when PCI was used for biometry, in 75% of cases, mea-
surements taken after pIOL implantation were unable to
identify the anterior surface of the crystalline lens correctly.
In these cases, when ACD and LT values measured with
AS-OCT were substituted and recalculations performed, no
difference was observed in preoperative and postoperative
IOL powers when using either the H or B formula.
When calculating IOL power, biometry, including
measurement of axial length, is exceedingly important.

Figure 2. Bland-Altman plots for

ACD and LT before and after pIOL
insertion. (A) ACD values mea-
sured using PCI, (B) ACD values
measured using AS-OCT, (C) LT
values measured using PCI, and
(D) LT values measured using AS-
OCT. Solid line: mean value of the
difference between the measured
values. Dashed line: upper and
lower bounds of the 95% CI. ACD
= anterior chamber depth; LT =
lens thickness; PCI = partial co-
herence interferometry; pIOL =
phakic IOL

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660 IMPACT OF PIOL IMPLANTATION ON BIOMETRY AND IOL CALCULATION

Table 2. Results of Biometry Before and After Implantation of Posterior Phakic IOL.
Biometry Preoperative Postoperative P valuea
Axial length (mm) 26.57 ± 1.27 26.58 ± 1.24 .79
Corneal power (D) 43.61 ± 2.13 43.52 ± 3.88 .43
ACD (mm)
PCI (all cases, n = 100) 3.72 ± 0.30 3.23 ± 0.34 <.001
PCI (no misidentification, n = 25) 3.79 ± 0.30 3.72 ± 0.35 .06
PCI (misidentification, n = 75) 3.71 ± 0.30 3.20 ± 0.34
AS-OCT 3.84 ± 0.28 3.79 ± 0.25 .05
LT (mm)
PCI (all cases, n = 100) 3.70 ± 0.33 4.19 ± 0.38 <.001
PCI (no misidentification, n = 25) 3.88 ± 0.30 3.83 ± 0.27
PCI (misidentification, n = 75) 3.84 ± 0.28 3.87 ± 0.23
AS-OCT 3.71 ± 0.30 3.77 ± 0.31 .08
ACD = anterior chamber depth; LT = lens thickness; misidentification = cases in which the segmentation line indicating the anterior surface of the lens was
mistakenly placed on the anterior surface of the posterior phakic IOL during postoperative measurement; PCI = partial coherence interferometry
a
One-sample t test

Previous comparisons of axial length measurements taken
before and after pIOL implantation did not report any
significant changes.8,9 Similarly, in our study, the difference
between pre-pIOL and post-pIOL implantation axial length
was only 0.01 mm, and was not statistically significant. The
mean axial length of the cases targeted in this study was
26.57 mm, a rather large value; this may have further
minimized the effects of changes in this value on calcu-
lations of IOL power. However, vitreous liquefaction and
posterior vitreous detachment are believed to occur early in
eyes with severe myopia, and particularly, in eyes with long
axial length. These factors are believed to lead to changes in
refraction in large volume areas of the eye and thereby
potentially affect the measurements of optical path
length.10 However, here, we compared preoperative and
early postoperative data (1 month postoperatively) and
considered that it was not necessary to take these other
factors into account. Furthermore, corneal power, another
important factor when calculating IOL power, is affected by
variables such as tearing during measurement, but in this
study population, the preoperative and postoperative dif-
ference in corneal power was less than 0.1 diopters (D).11
On the one hand, there were issues with ACD mea-
surement, and significant differences were observed in the
values measured preoperatively and postoperatively. Al-
though there have been several reports that used anterior
segment analysis devices to explore changes in ACD before
and after pIOL implantation, all these defined post-
operative ACD as the distance from the corneal endo-
thelium to the anterior surface of the pIOL, which is
different from the definition used in this report.4,5,12 On the
other hand, in an existing report that used an older PCI
model (IOL Master 500), postoperative measurements were
reported to have decreased by 0.27 mm.6 However, the IOL
Master 500 takes measurements using the lateral slit illu-
mination method. Not only does this method result in
intersubject reproducibility issues, but it is also quite likely
that this approach frequently misidentified the anterior
pIOL surface as the anterior lens surface. By contrast, in the
PCI used in this study (IOL Master 700), anterior depth
measurements were also based on optical coherence to-
mography images, and the ACD on the visual axis was
measured with good reproducibility. It seemed that, in 75%
of cases, the anterior surface of the pIOL was mistaken for
the anterior surface of the IOL. ACDs measured using PCI
differed by approximately 0.5 mm, which was larger than
that previously reported. LT measurements were also
greatly affected. Under these circumstances, it is clear that
IOL powers calculated using the H formula (which is based
on axial length and ACD) and the B formula (whose
specific equation has not been publicized, but which also
incorporates axial length and ACD) would be different. In
the aforementioned report in which the IOL Master 500
was used, although ACD measurements reduced by

Table 3. Estimated Lens Powers Before and After Implantation of Posterior Phakic IOL (Estimated Values Aiming for
Emmetropia With SN60WF as the Target Lens).
Postoperative
Formula Preoperative Postoperative P valuea substitution P valuea
SRK/T formula (D) 11.70 ± 3.53 11.61 ± 3.51 .29 11.61 ± 3.51 .29
Haigis formula (D) 12.05 ± 3.60 11.75 ± 3.53 <.001 12.02 ± 3.60 .16
Barret formula (D) 11.78 ± 3.43 11.57 ± 3.37 <.001 11.80 ± 3.43 .55

Barret formula: Barret universal II TK formula. Postoperative substitution: In cases where partial coherence interferometry could not place the segmentation line
correctly on the anterior surface of the lens, the anterior chamber depth and lens thickness, measured using AS-OCT, were substituted, and the values were
recalculated.
a
Repeated measures analysis of variance (Bonferroni adjustment)

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 IMPACT OF PIOL IMPLANTATION ON BIOMETRY AND IOL CALCULATION
0.27 mm after pIOL insertion, no difference was observed
in powers calculated using any of the formulas, including
the H or B formulas, for reasons that are not immediately
clear.6
Thus, in this study, after using AS-OCT to trace the
location of the measured value onto the surface of the
crystalline lens, we remeasured ACD and LT values.
However, despite this correction, postinsertion ACD and
LT values were 0.05 mm shorter and 0.06 mm longer,
respectively; we believe these discrepancies to have been
caused by manual error introduced during the tracing
process. Nevertheless, these differences were significantly
smaller than those engendered by PCI measurement. We
found that this process could be used to assist in the cal-
culation of IOL power. Ultimately, on substituting these
corrected values into the H and B formulas in cases where
misidentification had occurred, differences in powers cal-
culated before and after pIOL insertion disappeared.
The excellent accuracy of the B formula, which is gen-
erally classified as a fourth generation IOL power calcu-
lation formula, has been reported previously.13 The H
formula has also been reported to be as highly accurate as
the B formula, in eyes with axial length > 26.0 mm.14
However, as seen in this study, when used in individuals
with implanted pIOLs, there are certain conditions in
which both the H and B formulas are affected. On the other
hand, the S formula uses only axial length and corneal
power for calculations; neither of these parameters changed
with pIOL insertion. Furthermore, even if the H and B
formulas are used, if values are substituted by those
measured using AS-OCT, the estimated IOL powers no
longer differ from those calculated preoperatively.
This study had certain limitations. This was a single-
center preintervention/postintervention trial and included
a geographically limited population. Moreover, age-related
changes of corneal aberration, LT, or vitreous should be
considered further in actual clinical practice. Meier et al.
reported that 57.9% and 82% cases registered less than 0.5
D and 1.0 D postoperative refractive error using the S
formula in cataract surgery concurrent with pIOL
extraction.15
A main unresolved issue with these study results is that
because a small difference was observed even with mea-
surements taken using AS-OCT, it remains unclear
whether pIOL insertion truly shortens ACD or whether it
simply affects the fidelity of measurement techniques. In
addition to having low refractive power, all pIOLs are
concave lenses. Thus, they have, at most, a small impact on
light measured at the optical center. Nevertheless, cases
with pIOL correction for hyperopia, which involve a large
center thickness, need to be considered. Further studies
should be conducted once ACD measurement in pIOL-
implanted eyes has been fully automated.
In conclusion, if a patient with a pIOL requires cataract
surgery, it is possible to calculate IOL power without pre-
pIOL data. However, although the biometric measurement
can be used directly if applying the S formula, when the H
or B formulas are used, there is a need to verify whether the
661
PCI has correctly identified the anterior surface of the
crystalline lens. If a misidentification has occurred, AS-
OCT or another form of measurement must be used to
make correct ACD and LT measurements, and these values
can then be substituted back into the formula to obtain a
result approximating that which would have been calcu-
lated with measurements taken in the absence of the pIOL.
In the future, the aforementioned explorations of measured
values for ACD in pIOL-implanted eyes are necessary to
gain further insight into the factors at play in this situation.
WHAT WAS KNOWN
 Phakic IOL (pIOL) implantation surgery does not alter the axial
length but could potentially change the measured value of the
anterior chamber depth (ACD).
 IOL power calculation using the third or fourth generation formula
has shown excellent accuracy even in pIOL-implanted eyes.
 The impact of change of ACD on IOL power calculation
following pIOL implantation, using partial coherence in-
terferometry (PCI), has not been assessed.
WHAT THIS PAPER ADDS
 PCI measurement misidentifies the lens surface in 75% of
pIOL-implanted eyes.
 The estimated IOL power was significantly lower at post-pIOL
implantation according to the H and B formulas (both P < .001),
whereas the S formula was not affected.
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Disclosures: None reported. without permission from the journal.

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